Interstitial lung disease more than 40 years after a 5 year occupational exposure to talc

Pulmonary talcosis in the setting of cosmetic talcum powder use

Pulmonary talcosis is a rare pneumoconiosis that is difficult to diagnose and may progress to debilitating lung disease. Four types of talcosis are described in literature: talc-silicosis and talc-asbestosis secondary to inhalation in industry workers and talc-emboli in intravenous drug users that self-inject talc-containing oral tablets. Although found in common household products, talc is overlooked as a cause of pneumoconiosis. Talcosis caused by cosmetic face powder is even rarer. Here we discuss a woman in her 50s who developed talcosis from inhalation of cutaneous cosmetics two years prior, and how comprehensive history may be crucial in diagnosing this rare disease.

Associations between occupational and environmental exposures and organ involvement in sarcoidosis: a retrospective case-case analysis

Background

Sarcoidosis most commonly affects lungs and intrathoracic lymph nodes, but any other organ can be involved. In epidemiological studies, many occupational and environmental exposures have been linked to sarcoidosis but their relationship with the disease phenotype has barely been studied.

Objective

To investigate how occupational and environmental exposures prior to diagnosis relate to organ involvement in patients with sarcoidosis

Methods

We retrospectively studied patients seen at a sarcoidosis clinic between 2017 and 2020. Patients were included if they had a clinical presentation consistent with sarcoidosis and histologically confirmed epithelioid granulomas or had Löfgren syndrome. In a case–case analysis using multivariable logistic regression we calculated odds ratios (OR) of prespecified exposure categories (based on expert ascertainment) for cases with a given organ involvement versus cases without this organ involvement.

Results

We included 238 sarcoidosis patients. Sarcoidosis limited to pulmonary involvement was associated with exposure to inorganic dust prior to diagnosis (OR 2.11; 95% confidence interval [CI] 1.11–4.17). Patients with liver involvement had higher odds of contact with livestock (OR 3.68; 95% CI 0.91–12.7) or having jobs with close human contact (OR 4.33; 95% CI 1.57–11.3) than patients without liver involvement. Similar associations were found for splenic involvement (livestock: OR 4.94, 95% CI 1.46–16.1; close human contact: OR 3.78; 95% CI 1.47–9.46). Cardiac sarcoidosis was associated with exposure to reactive chemicals (OR 5.08; 95% CI 1.28–19.2) or livestock (OR 9.86; 95% CI 1.95–49.0). Active smokers had more ocular sarcoidosis (OR 3.26; 95% CI 1.33–7.79).

Conclusions

Our study indicates that, in sarcoidosis patients, different exposures might be related to different organ involvements—hereby providing support for the hypothesis that sarcoidosis has more than one cause, each of which may promote a different disease phenotype.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01818-5.

Delayed orbital fibrosing inflammation from a retained crayon

A 39-year-old woman presented with sudden onset of double vision, right upper eyelid swelling and ptosis, and orbital pain. Imaging revealed an irregular mass of the upper right orbit with central non-enhancing areas. Upon inquiry, the patient recalled an intraorbital trauma with a crayon in her childhood, 35 years ago. Via translid anterior orbitotomy, remnants of a blue crayon embedded in an orbital fat mass were removed. Histopathology showed scavenger reaction of macrophages and sclerosis. Energy-dispersive X-ray spectroscopy revealed the presence of silicate particles. Repeated courses of corticosteroids were given. The patient deteriorated with reduced vision and frozen globe owing to severe orbital fibrosis of the entire orbit.

Inhalation Toxicity of Talc

Respirable talc powder (RTP) is a complex mineral mixture of talc along with accessory minerals, including tremolite, anthophyllite, quartz, magnesite, dolomite, antigorite, lizardite, and chlorite. The industrial mining, milling, and processing of talc ore is associated with elevated incidences of fibrotic and neoplastic diseases, which are also seen among workers exposed to RTP in secondary industries and individuals using processed cosmetic talc for personal use. There is controversial evidence of a link between the talc-induced lung diseases and a potential contamination with asbestos fibers. This controversy is fueled by inadequate exposure data and the complex mineralogy and terminology of the accessory minerals. Talc aerosols exhibit a wide range of mineral habits, including particulates and fibrous structures that have dimensional and compositional characteristics related to the development of asbestos-related lung disease. The inhalation toxicology of RTP is based on the analysis of occupational hygiene and animal inhalation studies conducted between the 1940s and the 1990s and more recent mechanistic studies conducted both in vivo and in vitro. The review of talc toxicity studies reveals that the occupational studies provide only equivocal links between any of the components of the aerosols and the development of pulmonary cancer; however, there is substantial evidence of an association between the aerosols and pleural and pulmonary fibrosis and the development of nonmalignant respiratory disease. The animal inhalation and implantation studies appear to be less than optimal, which also appears to be true for the in vivo and in vitro studies. The mechanistic studies have identified the key pathogenic characteristics of asbestos to be long and thin fibers that are durable in lung tissues and fluids. Talc toxicity studies show that talc particles and fibers are durable and can remain in the lung for up to 40 years after the end of exposure. This extended tissue residence is considered to constitute a continuing tissue exposure that is capable of inducing the documented inflammatory and proliferative response. There is less consensus as to whether there is a threshold fiber length effect, as long, thin fibers (>5 μm) form only a small fraction of talc aerosols and the possible role of fibers >5 μm in the translocation from the lung to the pleura and their association with pleural fibrotic and carcinogenic lesions. Long, thin fibers are preferentially deposited in hot spots in the lung, such as airway bifurcations, areas typically associated with the development of lung cancer. The platy structures typical of talc can form oblate structures behaving more as fibers in the air stream, and these have also been shown to deposit preferentially in such locations. The review of the inhalation toxicity of talc provides a plausible explanation for the carcinogenic potential of RTP.

Blowing Balloons and Pulmonary Talcosis: An Uncommon Hazard

A 65-year-old nonsmoker man presented with bilateral upper lobe conglomerated calcific opacities with basal reticulations. The patient denied any significant occupational exposure. Repeated and persistent enquiry revealed an intense exposure to talc 20 years back, from blowing balloons stained with talc powder for a period of 1 year. To the best of our knowledge, only one case has been reported in the past with talcosis due to balloon blowing.

Pulmonary Talcosis in an Immunocompromised Patient

The first case of pulmonary talcosis or talc pneumoconiosis related to inhalation of talc during its extraction and processing in mines was described by Thorel in 1896. Pulmonary talcosis is most commonly seen secondary to occupational exposure or intravenous (IV) drug abuse and, occasionally, in excessive use of cosmetic talc. Based on literature review, there has been an increase in reported incidents of pulmonary talcosis due to various forms of exposure to the mineral. We report an 82-year-old man who is diagnosed with Philadelphia chromosome positive pre-B cell acute lymphoblastic leukemia (ALL) treated with palliative imatinib who presented with chronic hemoptysis and dyspnea shortly after his diagnosis. His symptoms were initially thought to be due to an infectious etiology due to his malignancy, immunocompromised state, and radiographic findings until high-resolution computerized tomographic (HRCT) findings showed a diffuse pulmonary fibrosis picture that prompted further questioning and a more thorough history inquiry on his exposure to causative agents of interstitial lung disease. Very often, patients do not recognize their exposure, especially in those whose exposure is unrelated to their occupation. Our case emphasizes the need for thorough and careful history taking of occupational and nonoccupational exposure to known causative agents of interstitial lung disease.

Elemental analysis of occupational granulomatous lung disease by electron probe microanalyzer with wavelength dispersive spectrometer: Two case reports

The parenchymal lung diseases caused by metal inhalation include interstitial fibrosis, giant cell interstitial pneumonitis, chemical pneumonitis, and granulomatous disease, among others. We reported two cases of granulomatous lung disease with occupational exposure to metal dusts other than beryllium. They had worked in the battery manufacturing industry for 7 years and in an aluminum-processing factory for 6 years, respectively. Chest high-resolution computed tomography showed diffuse micronodules, and histology of video-assisted lung biopsy specimens revealed granulomatous lesions in the pulmonary interstitium. Results of microscopic examination of the tissue with special stains for mycobacteria and fungi were negative. Analysis by an electron probe microanalyzer with a wavelength-dispersive spectrometer (EPMA-WDS) confirmed the presence of silicon, iron, aluminum, and titanium in the granulomas. In particular, aluminum was distributed in a relatively high concentration in the granulomatous lesions. Although chronic beryllium disease is well known as an occupational granulomatous lung disease, much less is known about the other metals that cause granulomatous reactions in humans. Our report pointed out manifestations similar to beryllium disease after other metal dust exposures, in particular aluminum exposure. To our knowledge, this is the first report showing two-dimensional images of elemental mapping in granulomatous lesions associated with metal inhalation using EPMA-WDS.

Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict

Pulmonary foreign body granulomatosis following intravenous administration of medications meant for oral use among drug addicts has been occasionally reported. This condition is often misdiagnosed because of its rarity, but rather due to its similarity to other pulmonary diseases that are more common. Here we report a case of pulmonary intravascular talcosis mimicking miliary tuberculosis in a young male intravenous drug addict from North-Eastern Estonia, known as a hotspot for tuberculosis and drug misuse. The condition was caused by intravenous administration of crushed tablets of diphenhydramine, but miliary tuberculosis was misdiagnosed on patient's demographical, clinical and radiological grounds and a decision to start treatment with four first-line antituberculosis drugs followed. The current report refers to the importance of considering rare causes of pulmonary disseminations with attempts to identify the causative agent and warns against the use of antituberculosis treatment without confirmation of microbiological diagnosis of tuberculosis.

Pathogenesis of sarcoidosis

Sarcoidosis is a systemic granulomatous disorder of unknown origin. Recent research uncovered underlying immunological and genetic mechanisms, which will pave the way for more effective pharmaceutical studies. At present some of this knowledge is clinically exploited to monitor therapy and expected genetic progress will allow the development of prognostic genetic patterns or molecular signatures. Moreover, it has become obvious that several etiologic agents and cofactors will exist. These will be of animate and inanimate nature and their interplay with host mechanisms discussed in this review determines disease phenotypes.

Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder

Pulmonary talcosis is a rare but debilitating variant of pneumoconiosis often presenting with isolated non-specific symptoms of progressive exertional dyspnoea or cough. Occupational exposure to talc dust and intravenous drug abuse are well-recognised aetiological factors with only a few cases related to cosmetic talc exposure being reported to date. The authors report a case of a young woman in whom a mere 4 month ritual of inhaling cosmetic talcum powder led to full-blown pulmonary talcosis being diagnosed 10 years later. The importance of a taking a pertinent history relating to environmental exposures in all patients presenting with respiratory symptoms is re-established here.

Pulmonary talcosis: imaging findings

Talc is a mineral widely used in the ceramic, paper, plastics, rubber, paint, and cosmetic industries. Four distinct forms of pulmonary disease caused by talc have been defined. Three of them (talcosilicosis, talcoasbestosis, and pure talcosis) are associated with aspiration and differ in the composition of the inhaled substance. The fourth form, a result of intravenous administration of talc, is seen in drug users who inject medications intended for oral use. The disease most commonly affects men, with a mean age in the fourth decade of life. Presentation of patients with talc granulomatosis can range from asymptomatic to fulminant disease. Symptomatic patients typically present with nonspecific complaints, including progressive exertional dyspnea, and cough. Late complications include chronic respiratory failure, emphysema, pulmonary arterial hypertension, and cor pulmonale. History of occupational exposure or of drug addiction is the major clue to the diagnosis. The high-resolution computed tomography (HRCT) finding of small centrilobular nodules associated with heterogeneous conglomerate masses containing high-density amorphous areas, with or without panlobular emphysema in the lower lobes, is highly suggestive of pulmonary talcosis. The characteristic histopathologic feature in talc pneumoconiosis is the striking appearance of birefringent, needle-shaped particles of talc seen within the giant cells and in the areas of pulmonary fibrosis with the use of polarized light. In conclusion, computed tomography can play an important role in the diagnosis of pulmonary talcosis, since suggestive patterns may be observed. The presence of these patterns in drug abusers or in patients with an occupational history of exposure to talc is highly suggestive of pulmonary talcosis.

Case report: silicatosis in a carpet installer

CONTEXT

Chronic exposure to talc in the course of carpet installation can result in pneumoconiosis.

CASE PRESENTATION

We present a case of a young carpet installer who was diagnosed with silicatosis of the lung. Review of occupational history revealed that the patient had been working as a carpet installer for approximately 15 years, since he was 15 years of age. The patient was exposed to talc in the course of his work.

DISCUSSION

Exposure to talc in the course of carpet installation has not been reported as a possible cause of pneumoconiosis. In this article we review different causes of silicatosis and discuss chronic exposure in the course of carpet installation and development of pneumoconiosis. In addition, we also review the relevance of mycobacterial infection in cases of silicosis and silicatosis.

RELEVANCE TO CLINICAL OR PROFESSIONAL PRACTICE

Exposure to talc in the course of carpet installation should be added to conditions that can cause pneumoconioses, specifically silicatosis of the lung.

Association of man-made mineral fibre exposure and sarcoidlike granulomas

It is assumed that sarcoidosis is caused by inhalation of air borne agents in susceptible persons triggering the inflammatory reaction. The association of metallic dust exposure, such as beryllium and aluminium, and sarcoidlike pulmonary disorders is well known. The ability of man-made mineral fibres (MMMF) to cause granulomatous lung disease has not been appreciated until now. Recently, we observed the association of sarcoidlike granulomatous reaction and occupational history of glass fibre exposure. We hypothesized that there might be a relationship between MMMF exposure and the development of sarcoidlike granulomas. Therefore, the records of 50 sarcoidosis patients-who visited our outpatient clinic between 1996 and 1999 were reviewed. This revealed that 14 cases recalled a history of exposure to either glass fibres or rock wool, both MMMF fibres. The available obtained tissue specimens (n = 12) were reviewed. In six cases electron microscopy qualitative analysis of small fragments of the tissue revealed among others silica, aluminium and sometimes titanium. A distinct relation between fibre deposits fibre deposits and granulomas was found. These findings indicate that in susceptible people MMMF exposure might be related to a chronic granulomatous disease similar to chronic beryllium disease.